tag:blogger.com,1999:blog-7476621888383604834.post4647741060402716114..comments2024-02-15T03:26:38.897-05:00Comments on Health Care Organizational Ethics: Nicholas Kristof on "Unhealthy America" - One Grand Slam and One StikeoutJim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-7476621888383604834.post-13054668221999565292009-11-15T16:19:42.396-05:002009-11-15T16:19:42.396-05:00Dear Anonymous -
Thank you for your very thoughtf...Dear Anonymous -<br /><br />Thank you for your very thoughtful, experience-based comments. <br /><br />How wise of you to consult with an ethicist about the strain-laden work that you do! I agree fully with the perspective the Catholic consultant gave. You might be interested in the September 10, 2007 post I wrote - "A Jewish Fan of Catholic Organizational Ethics." Apart from my disagreement with the standard Catholic positions on reproductive ethics I find the Catholic tradition of ethics very wise and humane.<br /><br />I've learned a lot from my colleagues in palliative care over the years. I agree that they have a lot to teach us about providing holistic, patient-centered care.<br /><br />My one disagreement is with your take on the British attitude toward NICE. There are constant arguments in the UK about NICE's decisions and the question of whether they have set the hurdle for cost effectiveness about right, too low or too high. But, unlike us in the U.S., there appears to be broad acceptance of what NICE is trying to do.<br /><br />Thank you for the kind comment about the work Norman Daniels and I have done. Not surprisingly, interest in that work has been limited in the U.S. but quite high in countries like England that have universal insurance coverage and an overall budget for health care.<br /><br />Best<br /><br />JimJim Sabinhttps://www.blogger.com/profile/03087828142188534542noreply@blogger.comtag:blogger.com,1999:blog-7476621888383604834.post-49947812016061899162009-11-15T12:58:46.427-05:002009-11-15T12:58:46.427-05:00Very appropriate that you should refer to Mother T...Very appropriate that you should refer to Mother Theresa in this context. As an author of medical policy, I struggle with these issues almost daily. The huge gap between oncologist and patient hopes and what the drugs can actually deliver is one of the toughest problems. We consulted the ethicist at a local Catholic health system, who simply explained the heart of the issue with two terms, not surprisingly of Latin derivation:<br /><br />Benevolence, bene (good) + volo (to desire), embraces all sufferers with open arms. We want to help anyone that has a medical need.<br /><br />Beneficence (bene + facio (to do) means actually doing good. Here your work in defining our stewardship responsibility comes in. Beneficence, the ethicist says, must sometimes say NO, because we simply cannot do all the good we wish we could. As you stated, often the problems is the lack of therapeutic tools adequate to the challenge. Other times we are forced to choose between helping one person at very high cost and helping many at a lower cost. Neither government nor private insurance can solve the latter problem because we all have limited budgets. <br /><br />One of the tough questions no one wants to answer is defining the "minimum meaningful" life extension of a dying patient. The NICE/NHS tried to do this with cost-utility analysis and received a clear reprimand from the British public. This would make an excellent topic for a future blog. <br /><br />As a psychiatrist, you will appreciate the role of the emerging palliative care movement in helping patients with incurable metastatic cancer. Rather than continuing to assault their bodies with the latest quasi-experimental treatment, we would much better serve them by stepping back and looking at the individual from a more holistic perspective. The question that often doesn't get adequate attention is, what else would you like to do with the remaining time you have to end your life well? This must be asked while the patient's functional status is still reasonably good, so that they can enjoy time with family, travel, do estate planning, complete unfinished projects or deal with unresolved spiritual issues.<br /><br />As clinicians, we have set ourselves unrealistic standards. We define success narrowly as eliminating a specific disease or symptom, returning the patient to good physical health. We must learn to accept our inability to be omnipotent and redefine success in such cases.<br /><br />The insurance company medical directors I know are good hearted people trying to help anyone they can. If overlooked information is brought to their attention, either patient history or clinical trial data, medical necessity is usually established without delay. The $500 benefit described by the previous commenter is a sad result of the rising cost of health insurance, driven mostly by increasing costs of care, not greedy insurers. If we cannot address this, neither government nor private sector will achieve more than temporary stop gaps.<br /><br />Unfortunately, no one wants to be the bearer of these bad tidings to the public. It would be political suicide. It is much easier for politicians to take a benevolent posture and let others break the bad news. Thanks for this column and the work that you and Dr. Daniels have done to articulate this problem. I wish you had as many readers as the NY Times.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7476621888383604834.post-10558836448052725682009-11-10T08:37:24.105-05:002009-11-10T08:37:24.105-05:00Dear Cancer Doctor -
What a painful situation! Un...Dear Cancer Doctor -<br /><br />What a painful situation! Unfortunately it's not uncommon. You and your office are doing heroic work, since specialists tend to clump in urban areas. Congratulations, and thank you, for what you do!<br /><br />If we simply looked at our national expenditures on cancer care we would see (a) tremendous waste in our use of very costly agents for which (b) there isn't a shred of evidence for effectiveness prescribed for (c) patients who are close to death and (d) would probably not want to be "flogged" with the treatment if they knew how unlikely any benefit was. And, alongside of this combination of waste and harm we would see what you describe - people who can't afford access to standard effective treatment that could make a huge difference in their lives.<br /><br />The American Society of Clinical Oncologists has been documenting this problem and conducting advocacy. It is important for the group to know about the situations you are describing.<br /><br />Thank you for your comment. And - keep up the good work!<br /><br />Best<br /><br />JimJim Sabinhttps://www.blogger.com/profile/03087828142188534542noreply@blogger.comtag:blogger.com,1999:blog-7476621888383604834.post-80017988695286728552009-11-10T07:00:14.356-05:002009-11-10T07:00:14.356-05:00I work in a rural community. Many of my patients ...I work in a rural community. Many of my patients do not have insurance or have minimal insurance. Some people buy cheap insurance only to find that it covers $500 of chemotherapy, which is basically non-insurance. Honest -- those types of policies are out there. It's in the contract that the patient signs. There is no appeal. Our office works hard at treating these patients, but although these patients are "insured" they are insured for very little.A Cancer Doctornoreply@blogger.com